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Background: The large and increasing number of adults living with dementia is a pressing societal priority, which may be partially mitigated through improved population-level blood pressure (BP) control. We explored how tighter population-level BP control affects the incidence of atherosclerotic cardiovascular disease (ASCVD) events and dementia., Methods: Using an open-source ASCVD and dementia simulation analysis platform, the Michigan Chronic Disease Simulation Model, we evaluated how optimal implementation of 2 BP treatments based on the Eighth Joint National Committee recommendations and SPRINT (Systolic Blood Pressure Intervention Trial) protocol would influence population-level ASCVD events, global cognitive performance, and all-cause dementia. We simulated 3 populations (usual care, Eighth Joint National Committee based, SPRINT based) using nationally representative data to annually update risk factors and assign ASCVD events, global cognitive performance scores, and dementia, applying different BP treatments in each population. We tabulated total ASCVD events, global cognitive performance, all-cause dementia, optimal brain health, and years lived in each state per population., Results: Optimal implementation of SPRINT-based BP treatment strategy, compared with usual care, reduced ASCVD events in the United States by ≈77 000 per year and produced 0.4 more years of stroke- or myocardial infarction-free survival when averaged across all Americans. Population-level gains in years lived free of ASCVD events were greater for SPRINT-based than Eighth Joint National Committee-based treatment. Survival and years spent with optimal brain health improved with optimal SPRINT-based BP treatment implementation versus usual care: the average patient with hypertension lived 0.19 additional years and 0.3 additional years in optimal brain health. SPRINT-based BP treatment increased the number of years lived without dementia (by an average of 0.13 years/person with hypertension), but increased the total number of individuals with dementia, mainly through more adults surviving to advanced ages., Conclusions: Tighter BP control likely benefits most individuals but is unlikely to reduce dementia prevalence and might even increase the number of older adults living with dementia., Competing Interests: Disclosures None.

Strategies to prevent or delay Alzheimer's disease and related dementias (AD/ADRD) are urgently needed, and blood pressure (BP) management is a promising strategy. Yet the effects of different BP control strategies across the life course on AD/ADRD are unknown. Randomized trials may be infeasible due to prolonged follow-up and large sample sizes. Simulation analysis is a practical approach to estimating these effects using the best available existing data. However, existing simulation frameworks cannot estimate the effects of BP control on both dementia and cardiovascular disease. This manuscript describes the design principles, implementation details, and population-level validation of a novel population-health microsimulation framework, the MIchigan ChROnic Disease SIMulation (MICROSIM), for The Effect of Lower Blood Pressure over the Life Course on Late-life Cognition in Blacks, Hispanics, and Whites (BP-COG) study of the effect of BP levels over the life course on dementia and cardiovascular disease. MICROSIM is an agent-based Monte Carlo simulation designed using computer programming best practices. MICROSIM estimates annual vascular risk factor levels and transition probabilities in all-cause dementia, stroke, myocardial infarction, and mortality in a nationally representative sample of US adults 18+ using the National Health and Nutrition Examination Survey (NHANES). MICROSIM models changes in risk factors over time, cognition and dementia using changes from a pooled dataset of individual participant data from 6 US prospective cardiovascular cohort studies. Cardiovascular risks were estimated using a widely used risk model and BP treatment effects were derived from meta-analyses of randomized trials. MICROSIM is an extensible, open-source framework designed to estimate the population-level impact of different BP management strategies and reproduces US population-level estimates of BP and other vascular risk factors levels, their change over time, and incident all-cause dementia, stroke, myocardial infarction, and mortality., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Burke et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: Our objective was to understand the reliability of profiling surgeons on average health care spending., Summary of Background Data: Under its Merit-based Incentive Payment System (MIPS), Medicare will measure surgeon spending and tie performance to payments. Although the intent of this cost-profiling is to reward low-cost surgeons, it is unknown whether surgeons can be accurately distinguished from their peers., Methods: We used Michigan Medicare and commercial payer claims data to construct episodes of surgical care and to calculate average annual spending for individual surgeons. We then estimated the "reliability" (ie, the ability to distinguish surgeons from their peers) of these cost-profiles and the case-volume that surgeons would need in order to achieve high reliability [intraclass correlation coefficient (ICC) >0.8]. Finally, we calculated the reliability of 2 alternative methods of profiling surgeons (ie, using multiple years of data and grouping surgeons by hospitals)., Results: We found that annual cost-profiles of individual surgeons had poor reliability; the ICC ranged from <0.001 for CABG to 0.061 for cholecystectomy. We found that few surgeons in the state of Michigan have sufficient case-volume to be reliably compared; 1% had the minimum yearly case. Finally, we found that the reliability of the cost-profiles can be improved by measuring spending at the hospital-level and/or by incorporating additional years of data., Conclusion: These findings suggest that the Medicare program should measure surgeon spending at a group level or incorporate multiple years of data to reduce misclassification of surgeon performance in the MIPS program.

Coverage and access have improved under the Affordable Care Act, yet it is unclear whether recent gains have reached those regions within states that were most in need of improved access to care. We examined geographic variation in Medicaid acceptance among Michigan primary care practices before and after Medicaid expansion in the state, using data from a simulated patient study of primary care practices. We used logistic regression analysis with time indicators to assess regional changes in Medicaid acceptance over time. Geographic regions with lower baseline (<50%) Medicaid acceptance had significant increases in Medicaid acceptance at 4 and 8 months post-expansion, while regions with higher baseline (≥50%) Medicaid acceptance did not experience significant changes in Medicaid acceptance. As state Medicaid expansions continue to be implemented across the country, policy makers should consider the local dynamics of incentives for provider participation in Medicaid.

Objectives: With insurance enrollment greater than expected under the Affordable Care Act, uncertainty about the availability and timeliness of healthcare services for newly insured individuals has increased. We examined primary care appointment availability and wait times for new Medicaid and privately insured patients before and after Medicaid expansion in Michigan., Study Design: Simulated patient ("secret shopper") study., Methods: Extended follow-up of a previously reported simulated patient ("secret shopper") study assessing accessibility of routine new patient appointments in a stratified proportionate random sample of Michigan primary care practices before versus 4, 8, and 12 months after Medicaid expansion., Results: During the study period, approximately 600,000 adults enrolled in Michigan's Medicaid expansion program, representing 57% of the previously uninsured nonelderly adult population. One year after expansion, we found that appointment availability remained increased by 6 percentage points for new Medicaid patients (95% CI, 1.6-11.1) and decreased by 2 percentage points for new privately insured patients (95% CI, -0.5 to -3.8). Over the same period, the proportion of appointments scheduled with nonphysician providers (nurse practitioners or physician assistants) increased from 8% to 21% of Medicaid appointments (95% CI, 5.6-20.2) and from 11% to 19% of private-insurance appointments (95% CI, 1.3-14.1). Median wait times remained stable for new Medicaid patients and increased slightly for new privately insured patients, both remaining within 2 weeks., Conclusions: During the first year following Medicaid expansion in Michigan, appointment availability for new Medicaid patients increased, a greater proportion of appointments could be obtained with nonphysician providers, and wait times remained within 2 weeks.

Background: We sought to develop a more reliable structured implicit chart review instrument for use in assessing the quality of care for chronic disease and to examine if ratings are more reliable for conditions in which the evidence base for practice is more developed., Methods: We conducted a reliability study in a cohort with patient records including both outpatient and inpatient care as the objects of measurement. We developed a structured implicit review instrument to assess the quality of care over one year of treatment. 12 reviewers conducted a total of 496 reviews of 70 patient records selected from 26 VA clinical sites in two regions of the country. Each patient had between one and four conditions specified as having a highly developed evidence base (diabetes and hypertension) or a less developed evidence base (chronic obstructive pulmonary disease or a collection of acute conditions). Multilevel analysis that accounts for the nested and cross-classified structure of the data was used to estimate the signal and noise components of the measurement of quality and the reliability of implicit review., Results: For COPD and a collection of acute conditions the reliability of a single physician review was quite low (intra-class correlation = 0.16-0.26) but comparable to most previously published estimates for the use of this method in inpatient settings. However, for diabetes and hypertension the reliability is significantly higher at 0.46. The higher reliability is a result of the reviewers collectively being able to distinguish more differences in the quality of care between patients (p < 0.007) and not due to less random noise or individual reviewer bias in the measurement. For these conditions the level of true quality (i.e. the rating of quality of care that would result from the full population of physician reviewers reviewing a record) varied from poor to good across patients., Conclusions: For conditions with a well-developed quality of care evidence base, such as hypertension and diabetes, a single structured implicit review to assess the quality of care over a period of time is moderately reliable. This method could be a reasonable complement or alternative to explicit indicator approaches for assessing and comparing quality of care. Structured implicit review, like explicit quality measures, must be used more cautiously for illnesses for which the evidence base is less well developed, such as COPD and acute, short-course illnesses.

Responsiveness is an important property of an outcomes questionnaire. It can be defined as the ability of an instrument to capture important changes in a patient's health status over time. The authors previously designed the Michigan Hand Outcomes Questionnaire (MHQ), a hand-specific outcomes instrument that contains six distinct scales: (1) overall hand function, (2) activities of daily living, (3) pain, (4) work performance, (5) aesthetics, and (6) patient satisfaction with hand function. In the first study, the authors demonstrated that the MHQ is a reliable and valid instrument for the hand. The purpose of this second study is to assess the responsiveness, or sensitivity, of the MHQ to clinical change in patient status. A total of 187 consecutive patients with chronic hand disorders completed a baseline MHQ prior to receiving treatment at a university plastic surgery clinic. Approximately 6 to 18 months after completing the first questionnaire, patients were sent a follow-up MHQ by mail. The second questionnaire was identical to the first, with the exception of one additional question added to each of the six MHQ scales. This additional question asked patients to rate the change in their hands since completing the last questionnaire using a seven-point response scale. Spearman's correlation coefficient was used to correlate the responses from patients' self-assessment questions with the actual score change (after score - before score). The response rate for the second administration was 49% (92 questionnaires returned)-a fairly good rate of return for mail surveys. There were no significant differences in gender, race, education, and income between responders and nonresponders. When patients' self-assessment of change was correlated with the change in the six scale scores over time, all six correlations were statistically significant, with p < 0.05. The correlations ranged from 0.25 for the aesthetics scale to 0.43 for the pain scale. The MHQ was responsive using patients' self-assessment of their clinical change. Future studies will evaluate the responsiveness of the MHQ compared with objective physiological measures such as grip strength, range of motion, and the Jebson-Taylor test. Additionally, research is underway to assess the responsiveness of the MHQ for specific procedures, including metacarpophalangeal arthroplasties for rheumatoid arthritis and microvascular toe-to-hand reconstructions.

Patients' desires and expectations for medical care warrant scrutiny because of their potential influence on health care use and patient satisfaction and their effects on patients' perceptions of quality of care. To determine if desires and expectations for selected elements of medical care and specialty referral differ between VA outpatients and non-VA outpatients, we conducted a cross-sectional survey of patients at a VA medical center site and 2 primary care sites of its university affiliate. Of 390 eligible patients at the VA medical center site, 270 (69%) consented to participate and returned completed self-administered questionnaires. At its university affiliate sites, 119 (73%) of the 162 eligible patients completed questionnaires. Overall, patient desire and expectation for elements of medical care and specialty referral were similar and high at all study sites. Desire ranged from 33% for a blood test to check for anemia to 80% for heart auscultation. Desire for specialty referral for hypothetical scenarios averaged 71% and 61% among VA Medical Center patients and university affiliate patients, respectively. Patient demographics and socioeconomic status were poor predictors of desire for care. These results suggest (a) that VA medical center outpatients' desires and expectations for preventive medical care are not significantly different from those of non-VA outpatients, (b) that desire is often high for both highly recommended care and care that is not generally recommended or is controversial, and (c) that high levels of desire are not limited to patients of higher levels of socioeconomic status. In an effort to improve satisfaction, it is important to examine ways in which to address patients' desires and expectations for medical care, even while faced with competing health care spending priorities.

In this study, psychometric principles were used to develop an outcomes questionnaire capable of measuring health state domains important to patients with hand disorders. These domains were hypothesized to include (1) overall hand function, (2) activities of daily living (ADL), (3) pain, (4) work performance, (5) aesthetics, and (6) patient satisfaction with hand function. An initial pool of 100 questions was pilot-tested for clarity in 20 patients; following factor analysis, the number of questions was reduced to a 37-item Michigan Hand Outcomes Questionnaire (MHQ). The MHQ, along with the Short Form-12, a generic health status outcomes questionnaire, was then administered to 200 consecutive patients at a university-based hand surgery clinic and was subjected to reliability and validity testing. The mean time required to complete the questionnaire was 10 minutes (range, 7-20 minutes). Factor analysis supported the 6 hypothesized scales. Test-retest reliability using Spearman's correlation demonstrated substantial agreement, ranging from 0.81 for the aesthetics scale to 0.97 for the ADL scale. In testing for internal consistency, Cronbach's alphas ranged from 0.86 for the pain scale to 0.97 for the ADL scale (values >0.7 for Cronbach's alpha are considered a good internal consistency). Correlation between scales gave evidence of construct validity. In comparing similar scales in the MHQ and the Short Form-12, a moderate correlation (range, 0.54-0.79) for the ADL, work performance, and pain scales was found. In evaluating the discriminate validity of the aesthetics scale, a significant difference (p = .0012) was found between the aesthetics scores for patients with carpal tunnel syndrome and patients with rheumatoid arthritis. The MHQ is a reliable and valid instrument for measuring hand outcomes. It can be used in a clinic setting with minimal burden to patients. The questions in the MHQ have undergone rigorous psychometric testing, and the MHQ is a promising instrument for evaluation of outcomes following hand surgery.

To explore whether patients' desires for and expectations of medical care differ between the United States and Canada, we surveyed 652 patients and 105 physicians at primary care sites in Michigan and Ontario. Patient desires were similar at both sites, but expectations were higher in Michigan. Michigan physicians gave higher estimates of patient desire than physicians in Ontario. Physicians at both sites, however, similarly underestimated patients' desires. These between-site differences in expectation may reflect differences both in general cultural factors and in patient exposure to different clinical policies within the medical systems.

Objectives: Many groups involved in health care are very interested in using external quality indices, such as risk-adjusted mortality rates, to examine hospital quality. The authors evaluated the feasibility of using mortality rates for medical diagnoses to identify poor-quality hospitals., Methods: The Monte Carlo simulation model was used to examine whether mortality rates could distinguish 172 average-quality hospitals from 19 poor-quality hospitals (5% versus 25% of deaths being preventable, respectively), using the largest diagnosis-related groups (DRGs) for cardiac, gastrointestinal, cerebrovascular, and pulmonary diseases as well as an aggregate of all medical DRGs. Discharge counts and observed death rates for all 191 Michigan hospitals were obtained from the Michigan Inpatient Database. Positive predictive value (PPV), sensitivity, and area under the receiver operating characteristic curve were calculated for mortality outlier status as an indicator of poor-quality hospitals. Sensitivity analysis was performed under varying assumptions about the time period of evaluation, quality differences between hospitals, and unmeasured variability in hospital casemix., Results: For individual DRG groups, mortality rates were a poor measure of quality, even using the optimistic assumption of perfect casemix adjustment. For acute myocardial infarction, high mortality rate outlier status (using 2 years of data and a 0.05 probability cutoff) had a PPV of only 24%, thus, more than three fourths of those labeled poor-quality hospitals (high mortality rate outliers) actually would have average quality. If we aggregate all medical DRGs and continue to assume very large quality differences and perfect casemix adjustment, the sensitivity for detecting poor-quality hospitals is 35% and PPV is 52%. Even for this extreme case, the PPV is very sensitive to introduction of small amounts of unmeasured casemix differences between hospitals., Conclusion: Although they may be useful for some surgical diagnoses, DRG-specific hospital mortality rates probably cannot accurately detect poor-quality outliers for medical diagnoses. Even collapsing to all medical DRGs, hospital mortality rates seem unlikely to be accurate predictors of poor quality, and punitive measures based on high mortality rates frequently would penalize good or average hospitals.

There is widespread interest in using external quality measures, such as early re-admission rates (ERRs), to evaluate hospital quality. To evaluate the feasibility of using ERRs to identify poor-quality hospitals, a Monte Carlo simulation model was developed that describes the predictive power of ERRs for the 190 hospitals in Michigan using different assumptions concerning the distribution and variability of quality problems, the number of years of data aggregated, and unmeasured case-mix differences. The ability of ERRs to distinguish 171 average-quality hospitals from 19 poor-quality hospitals (assigned to have 5% vs. 15% premature discharges) was evaluated. First, the largest diagnosis-related groups (DRGs) were studied to determine if they included cardiac, gastrointestinal, pulmonary, and neurologic diseases. Despite using the highly optimistic assumptions that premature discharges are readmitted 50% more frequently than appropriately timed discharges and that no ERR variation was caused by unmeasured case-mix differences between hospitals, the results were poor. For example, for DRG 127 (heart failure), high ERR outlier status (using a .05 probability cutoff) had a positive predictive value of only 36%, meaning that approximately two thirds of hospitals labeled "poor-quality" (high ERR outliers) were false-positive results. Next, we repeated the simulation with sample sizes aggregated for all medical DRGs. The positive predictive value was 72%, but was very sensitive to ERR variability due to non-quality-related factors (e.g., unmeasured case mix). The positive predictive value decreases to 45% if unmeasured case mix accounts for even 10% of observed hospital ERR variation. The circumstances under which DRG-specific ERRs would be useful to detect poor-quality hospitals are unlikely to occur. Even collapsing to all medical DRGs, ERRs are likely to be accurate predictors only if quality differences are quite large and if unmeasured case-mix differences account for a small amount of interhospital variation in ERRs.